1. This question would require an essay.
2. Depends.
3. Yes. If you only learned what was published, you'd be missing out on a lot.
4. There's always still a lot to discover and learn. Think of it as an opportunity.
Physical Therapy Effectiveness: Questions from a New Student
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1. This question would require an essay.
2. Depends.
3. Yes. If you only learned what was published, you'd be missing out on a lot.
4. There's always still a lot to discover and learn. Think of it as an opportunity.
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The point I am trying and maybe failing to make is that the placebo effect is not something to be avoided, it should be embraced, but we should do our best to work from a model that is if not supported by good evidence, at least plausible and have some basis in science. I share some of the frustrations you have with so many "techniques" being shown to not really have the mechanical effects that our theories predict.
Simplify your professional life. If it moves too much, stabilize, if moves to little, mobilize. Our bodies like the middle (whether it is range of motion, blood pressure, blood sugar, or the amount of exercise we do) and help your patients get themselves more in the middle. Do so confidently and you will sleep just fine at night and your patients will also have confidence in what you say BOOM placebo is helping too.
BTW. I'm not mad or frustrated other than my inability to explain my point of view. I think Circa is asking genuine questions from a standpoint of really trying to learn, not to troll.
Hey everyone OP here. I guess my main issue is that I keep hearing physical therapists tell me that certain interventions are evidence based. But when I ask to name a specific intervention for a specific issue, they are not able to tell me one and often say my question is too broad. I think that question is very specific. I just want to know a specific intervention that is well backed by evidence. From there I am hoping to find a specialty which leans away from the placebo (I think using the placebo is fine but I am unwilling to get a clinical doctorate in something that is mainly placebos). I am frustrated continually hearing about the theories that support interventions instead of the evidence supporting those theories. There are plenty of theories in medicine and science that turned out to have evidence against them. Most MSK interventions I can find studies on are inconclusive in their efficacy beyond placebo or proven to be the same as placebo. The same is often true for systematic reviews on intervention efficacy. The most evidence I have seen for MSK issues supports short term changes with no changes long term. I guess I am just feeling frustrated that most of the PT's I have interned with just go with the flow and do not scrutinize what they were taught or care to read new research. I am getting the impression that the profession as a whole is unwilling to self-critique and overly focused on marketing.
On a brighter notes I have found the research surrounding task-training for neuro patients to be well evidenced. I think early mobilization for ICU is well evidenced. I also think a lot of pediatric work is well evidenced. My concern is that the majority of the profession is a bunch of people bull****ting themselves with anecdotal placebo experiences. I will go to school if there is a speciality I can be confident in. But I am really uncomfortable with how expensive and common place a lot questionable treatment is, and I am concerned I will only find a small sliver of interventions to be legitimate enough for me.
I think in the end I might just want something more concrete. Something where the theories are well evidenced or self-evident, and where practice is more uniform because intervention to outcome is more certain. I am really turned off by the "art" of the profession because I have seen that term used to mask some very questionable practices.
I am sorry if I sound bitter or if this gets to emotional. This profession is just something I spent a lot of years preparing for and the closer I am getting to it the more I am realizing it might not be what I thought it was.
On a brighter notes I have found the research surrounding task-training for neuro patients to be well evidenced. I think early mobilization for ICU is well evidenced. I also think a lot of pediatric work is well evidenced. My concern is that the majority of the profession is a bunch of people bull****ting themselves with anecdotal placebo experiences. I will go to school if there is a speciality I can be confident in. But I am really uncomfortable with how expensive and common place a lot questionable treatment is, and I am concerned I will only find a small sliver of interventions to be legitimate enough for me.
I think in the end I might just want something more concrete. Something where the theories are well evidenced or self-evident, and where practice is more uniform because intervention to outcome is more certain. I am really turned off by the "art" of the profession because I have seen that term used to mask some very questionable practices.
I am sorry if I sound bitter or if this gets to emotional. This profession is just something I spent a lot of years preparing for and the closer I am getting to it the more I am realizing it might not be what I thought it was.
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Then don't go to school?
Oh and marketing is 20x worse for things like elective plastics and Ortho surg. IPM and sports med injections break the meter
Yeah that is the conclusion I am coming to. I have just been trying to reach out to see if I am wrong in my views, because I really want to be convinced otherwise. It is hard for me to accept my own viewpoint when the PT field is growing so steadily, and I meet so many people who are at least very outwardly confident in it. I know truth and evidence is not democratic, but I feel like I must not understand something about the profession that actual physical therapists do. It is just too big of a gamble for me to go to school when I do not know if the answers I want are there or not.
I also do not like when people tell me that medicine or plastic surgery do the same things. For me that just means both fields are in the wrong and it doesn't justify any of it. I am sure you recognize this, but I just wanted to say it.
I really appreciate everyone who responded to this thread and I am glad it created discussion. It is nice to see there are other students who are nervous about what they are learning. It is also nice to see people defending the profession. This is the discussion I wanted.
I also do not like when people tell me that medicine or plastic surgery do the same things. For me that just means both fields are in the wrong and it doesn't justify any of it. I am sure you recognize this, but I just wanted to say it.
I really appreciate everyone who responded to this thread and I am glad it created discussion. It is nice to see there are other students who are nervous about what they are learning. It is also nice to see people defending the profession. This is the discussion I wanted.
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Medicine can be vicious. Period.
Unfortunately I don't see it getting any better until the educational pathways stray away from debt so that clinicians can charge cash and not be tied to insurance companies and the pressure to Bill. It would give clinicians power over their on profession more. Unless you understand all of healthcare dynamics, that statement may be hard to understand though.
Healthcare operates off of the best of what we've got. There aren't absolutes outside of this didn't cause a fatality or objective measurements showing improvement. You practice following evidence. There is always uncertainty and some level of placebo. The ethics are to practice following the evidence without marketing gimmicks or non specific effects as the treatment.
Healthcare is a business. It's finding the balance between ethics, making a living, and enhancing patient quality of life the best way that you can while following best literature and practice patterns.
It's understandable if you don't wanna make the jump. It's your decision. The fields aren't 'wrong' though.....INDIVIDUALS in the fields can be very wrong though. Hence, difficulty in acceptances to schools through interview and personal statements.
There are balances and trade offs.
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Yeah I have met a lot individuals who are unwilling to follow evidence. And it seems like there are other healthcare fields where there is more evidence, more certainty and less placebo. It just seems daunting to enter the profession when I feel like I am fighting a tide.
Out of curiosity, was there any area of PT that you found to be solidly evidenced in the majority of its practices? By area I mean something along the lines of neuro, in-patient post surgical ortho rehab, cardiac rehab. Or maybe just an area that a PT could work in exclusively.
Out of curiosity, was there any area of PT that you found to be solidly evidenced in the majority of its practices? By area I mean something along the lines of neuro, in-patient post surgical ortho rehab, cardiac rehab. Or maybe just an area that a PT could work in exclusively.
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All of them. The level to which is based on your own practice and drive
I see. I was more asking as they were taught rather than as you chose to practice them. But I do understand you are driven in your practice and most likely practice with evidence. I'm gonna call it a night. I appreciate your comments.
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I share some of your frustration but I think that the reason that some of the things that we do is that there are dozens of contributing factors to many aches and pains. for example, Patello-femoral syndrome can result from: poorly controlled pes planus, bad shoes, problematic training methods, quad tightness, gluteal tightness, ITB tightness, trauma, tight gastroc, tight soleus etc . . . so when research is done regarding PFS they will look at one variable. The "n"s in physical therapy research are too small to cancel out all of the other potential contributors to the diagnosis. Therefore, rarely does a MSK diagnosis show a dramatic improvement in the literature. I know that you hate the word "art" and I agree that it covers up some truly snake oil treatments but I know that my PFS patients get better. I look at all of the things I mentioned and more and identify those things that could contribute to their symptoms and address them. I am not picking one, I am working on many. Research rarely is able to do that. I think that the problem is that the right clinical questions are not being asked. In many cases the researches are trying to test one variable only and life is not like that. If you still love the idea of physical therapy, maybe you can go into clinical research and ask the right questions.
The question for me is why are your patients getting better and would they get better without you or if some average joe applied a sham treatment to them. I am sure you have treated people who have had issues for a very long time and then the issue has been resolved within maybe a couple weeks or months. In that case, I would also be pretty confident that something you did is working and I think you would be justified in thinking that. Unfortunately, much of the PT that I have shadowed is during a recovery period (say after a surgery) where it is hard to tell if the intervention is expediting recovery. Most treatment I have seen is effective in the short term for symptomatic treatment, but I am unsure about its effectiveness beyond that. I am pretty confident in prescribed exercise having a significant effect on chronic conditions though given the studies I have read and the results I have seen. So there are just some major areas of PT where I have some serious skepticism, but also other areas where I have confidence in the interventions. I am just doing my best to weight my doubt versus my confidence.
I have definitely thought about research. I have a strong desire to try to press the field in the direction I think is right, but I honestly am not sure if I have the fortitude and the discipline to do so. I much prefer hands-on, problem-solving work and my time working in an exercise science lab was not the best experience as far as something I would want to do for the rest of my life.
Seriously thank you for responding, especially after this thread has been up for so long. I am doing my best to provoke some good discussion without being viewed as antagonistic, as I love the PT field.
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Average Joes can't treat because they don't know anatomy, biomechanics, kinesiology, and applying forces that facilitates the best tissue remodeling. Remodeling is going to be a big topic for research for creating practice parameters as there aren't definitive guidelines yet although average tissue healing timelines exist within the literature and we have rehab stages for when to progress without injury.
I think you're oversimplifying treatments. Without knowing the anatomy and what causes different forms of pain (immune system due to inflammation from injury, immune system fighting infections, cardiovascular system receptors, receptors from selective tissue tension testing allowing isolation of injury to ligaments or muscle, neural tension testing to isolate nerves, screening measures to point to a psychological/emotional source leading to pain amplification as the brain registers the input) you can't do the correct manual therapy or the correct relaxation or graded exercise techniques that produce positive outcomes.
As for expediting recovery: 100%
Ever seen scar tissue build up to the point that someone's range of motion is only a few degrees? How about massive edema that reopens a wound because manual lymphatic drainage wasn't used properly? Atrophy around surrounding tissues?
If injuries aren't rehabbed along the lines of growth and maturation, then won't get strong and you won't optimize osteo and arthrokinematic movement. Unless you spend that first year of school learning every nook and cranny of anatomy and the neuromusculoskeletal system before building upon your knowledge in years two and three, you won't be able to help patients properly.
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It happens all of the time. People have been dealing with a set of symptoms for years, and/or have been seeing a chiropractor for months. They come to me, I look at the person, figure out why they hurt (sometimes its the tissues, sometimes its their incomplete understanding of the diagnosis - see nocebo) make recommendations and they are vastly improved at a rate that is not consistent with the previous trajectory. Not everything I do is supported in a paper somewhere but like I said, everything I do is evidence based, just not maybe a double blinded study that has been published. see post #61.
Yeah with the average joe thing I understand they can't treat as a PT would. My question is if their sham/fake treatment would have a similar effect since patients often respond positively to having anything done to them. It makes me feel better though that you are so confident with expediting recover, though I wish those definitive remodeling guidelines did exist. It would make me feel more confident in judging when a PT's intervention expedited the process. I 100% agree though that proper wound and scar tissue care expedites the process.
When I use the term treatment I just mean a PT who knows all the things you mentioned to the best of their knowledge and practices the manual therapy or the relaxation or graded exercise techniques to the best of their ability. So I am trying not to simplify the treatment, just to question whether the complex treatment, when applied correctly in all its complexity, is efficacious.
Thank you again for your responses. Also if you guys are finding this tiresome you can feel free to tell me. But if you do not remind replying, I feel like I am learning a lot.
As long as you are confident that the rate is not consistent due to your specific intervention, then I definitely feel like this is a convincing point. It might be anecdotal, but the differences in rates of recovery is very hard to deny. The only thing I think I could possibly be skeptical about in regards to that is if a sham treatment would cause the same difference in rates of recovery. In some literature I have seen this be the case, but with chronic conditions the actual intervention tends to be significantly better than a sham treatment. That's good stuff man.
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When I read the literature, they are most often saying things like "the type of shoe someone wears does not significantly impact whether or not they have ___" insert plantar fasciitis, Achilles tendinitis, patella-femoral pain, Morton's neuroma etc . . .
the paper that they wrote almost always ignores the fact that all of those diagnoses have multifactorial causes (contributors is a much better word IMO). Shoes may be a part of it, but changing shoes does not fix the problem. therefore, no significant impact statistically, it doesn't work. BUT, a regimen of better shoes, better flexibility, better balance (neuromuscular control) and relative rest (running 20 miles per week instead of 40 for a week or two) DOES have an impact. In an effort to decide if shoes (in this example) "fix" diagnosis X it will always fail because it is not the complete problem.
LBP is another example. Probably the most well studied program for treatment of LBP is the McKenzie approach. Not everyone responds to McKenzie as it is commonly understood. Some people prefer flexion. Some people have tight hamstrings, some have tight iliopsoas, some have weak core mm, some have "stupid" core muscles (i.e. they don't contract when they are supposed to), some use poor lifting technique, some do not rotate in the hips when doing transverse plane activities, some don't have enough rotation available in the hips, some have a leg length discrepancy. MOST people have several of these things.
You don't automatically have a heart attack if you smoke, but it increases your risk. (as does obesity, hypertension, elevated cholesterol, lack of exercise, and most importantly family history)
Research often tries to tease out one particular variable, manipulate it and come to a rousing conclusion about its effectiveness in treating a particular diagnosis. I have been working 25 years as a PT and in my experience, things rarely hurt for only one reason.
I am afraid that most of life is like this. Sales, for example. An effective salesman will need to be able to use a different pitch to different people. Public speaking - speak to the audience. If I am speaking to a bunch of PTs I can approach it one way, physicians, another, plumbers, yet another. There are very few cookbooks that work in the world. there is always a curveball. Getting out of school, I wanted to know what do I do when my patient has X. What was the "protocol"? When do I progress?
As I practiced I learned that there are dozens of options. If you expect there to be a cookie cutter job, it might be on a factory assembly line where each day is the same, the assignment is crystal clear, and there is no thought or problem solving involved, just memorization of if-then rules.
You don't strike me as that type of person, I just think that maybe your understanding about life sciences is a little too academic.
the paper that they wrote almost always ignores the fact that all of those diagnoses have multifactorial causes (contributors is a much better word IMO). Shoes may be a part of it, but changing shoes does not fix the problem. therefore, no significant impact statistically, it doesn't work. BUT, a regimen of better shoes, better flexibility, better balance (neuromuscular control) and relative rest (running 20 miles per week instead of 40 for a week or two) DOES have an impact. In an effort to decide if shoes (in this example) "fix" diagnosis X it will always fail because it is not the complete problem.
LBP is another example. Probably the most well studied program for treatment of LBP is the McKenzie approach. Not everyone responds to McKenzie as it is commonly understood. Some people prefer flexion. Some people have tight hamstrings, some have tight iliopsoas, some have weak core mm, some have "stupid" core muscles (i.e. they don't contract when they are supposed to), some use poor lifting technique, some do not rotate in the hips when doing transverse plane activities, some don't have enough rotation available in the hips, some have a leg length discrepancy. MOST people have several of these things.
You don't automatically have a heart attack if you smoke, but it increases your risk. (as does obesity, hypertension, elevated cholesterol, lack of exercise, and most importantly family history)
Research often tries to tease out one particular variable, manipulate it and come to a rousing conclusion about its effectiveness in treating a particular diagnosis. I have been working 25 years as a PT and in my experience, things rarely hurt for only one reason.
I am afraid that most of life is like this. Sales, for example. An effective salesman will need to be able to use a different pitch to different people. Public speaking - speak to the audience. If I am speaking to a bunch of PTs I can approach it one way, physicians, another, plumbers, yet another. There are very few cookbooks that work in the world. there is always a curveball. Getting out of school, I wanted to know what do I do when my patient has X. What was the "protocol"? When do I progress?
As I practiced I learned that there are dozens of options. If you expect there to be a cookie cutter job, it might be on a factory assembly line where each day is the same, the assignment is crystal clear, and there is no thought or problem solving involved, just memorization of if-then rules.
You don't strike me as that type of person, I just think that maybe your understanding about life sciences is a little too academic.
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@blob2121 - This:
It is almost impossible to submit most PT interventions to the type of scientific rigor that you are expecting. In particular, manual therapy is a difficult intervention to blind the subject and the researcher to. Add in the fact that there is no major company (i.e. a pharmaceutical company)willing to fund a large scale trial of PT interventions because there is no financial reward for them to do so and I have my doubts that we are ever going to see the type of research that physicians like to use when determining best practices.
Additionally, academic inquiry addresses one question at a time typically. Such as, "Does intervention X work?". Clinical inquiry doesn't work like that - a 50 year old male comes to me with (R) shoulder pain, he has essentially 4 options to consider in regards to addressing it: do nothing, consider drugs (oral or injected), rehab, or consider surgery. The relevant clinical questions at that time are as follows: what interventions have been shown to be helpful, of those which are the least invasive and offer the lowest chance of adverse events, are there any contraindications to those interventions with this patient, and what does the patient want to do?
There is a growing body of evidence that suggests that PT can be just as effective, if not more so, than surgery for many conditions commonly seen in our health care system. There is virtually no risk to a trial of common PT interventions and most patients (correctly) feel that surgery should be a last resort. Taking all of this into consideration, I think PT would be the best choice for this patient at this point in time. IF some of the variables change, then the best choice for the patient may change.
We all would like to see studies of common PT interventions where n=1,000, but we spend all day treating where n=1.
It is almost impossible to submit most PT interventions to the type of scientific rigor that you are expecting. In particular, manual therapy is a difficult intervention to blind the subject and the researcher to. Add in the fact that there is no major company (i.e. a pharmaceutical company)willing to fund a large scale trial of PT interventions because there is no financial reward for them to do so and I have my doubts that we are ever going to see the type of research that physicians like to use when determining best practices.
Additionally, academic inquiry addresses one question at a time typically. Such as, "Does intervention X work?". Clinical inquiry doesn't work like that - a 50 year old male comes to me with (R) shoulder pain, he has essentially 4 options to consider in regards to addressing it: do nothing, consider drugs (oral or injected), rehab, or consider surgery. The relevant clinical questions at that time are as follows: what interventions have been shown to be helpful, of those which are the least invasive and offer the lowest chance of adverse events, are there any contraindications to those interventions with this patient, and what does the patient want to do?
There is a growing body of evidence that suggests that PT can be just as effective, if not more so, than surgery for many conditions commonly seen in our health care system. There is virtually no risk to a trial of common PT interventions and most patients (correctly) feel that surgery should be a last resort. Taking all of this into consideration, I think PT would be the best choice for this patient at this point in time. IF some of the variables change, then the best choice for the patient may change.
We all would like to see studies of common PT interventions where n=1,000, but we spend all day treating where n=1.
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1. There's never enough evidence for anything, including those for all fields of healthcare. No one is ever confident to say that 'XYZ is 100% effective' based on their research. The beauty of the physical therapy field is that you use your brain to sort through what is good and what is bad to ultimately help your patients. If you want an answer that is definitive, then any healthcare profession is not for you, as each person is different, there are so many variables for each individual, and it's never concrete even with substantial research.
I mean, back in the day, doctors used to bleed out or attach leeches to their patients without much evidence...would that mean being a doctor is a total sham? Science is always improving.
2. Future research provides evidence for the use of PT. PT is a relatively newer profession and have only started making its mark in the healthcare profession. Part of the profession is to justify its importance to the world with research-backed materials.
3. You're less likely to be taught by anything pseudo-scientific in your program. If anything, your program should be stressing the importance of research-based interventions, along with instructing you to properly sort through which research are considered quality and which are garbage. I would check to make sure your school is accredited by APTA, as they have to follow their strict guidelines on how they teach their curriculum.
4. You'll see more "evidence"-based in areas where the patient's conditions are more pronounced because it's drastic enough to whether you can compare them pre- and post-therapy.
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It seems to me that you very caught up on the idea of "evidence". Let that go. Observations and doing your own personal research can only give you so much insight. It's only when you fully dive into school, is when you actually learn about the profession itself. And what you learn in school is just the tip of the iceberg. PT and healthcare in general, is a forever evolving profession. It's never perfect and there's always going to be a better way to do things. And that is our job as clinicians to help promote and find those efficient ways.
If you are hellbent on finding something that is 100% factual, then any science-related field is not for you. PT would not be for you. You're better of doing computers, where coding is black and white. Any healthcare profession forces you to be flexible and you either choose to adapt to that or you get pushed out and remain at a standstill. Every patient you meet is different and responds to different things. One of my instructor's favorite line is "It depends". And it really does depend.
We are taught theory from scientific findings just like any other healthcare profession. How we critically think and apply it is what makes us valuable in our profession. Plus, you'll always learn in this field. If you aren't, then you are doing something wrong.
To get this out of the way: You're not going to be able to save every one of your patients. That is going to be a fact. You can try anything and everything and there's still going to be that patients that won't make progress or even decline. Any healthcare staff is going to have to accept that truth. There's only so much we can do as humans. No amount of evidence is going to change that. It'd be great if there is one protocol for one condition, as it would make things a whole of a lot easier, but that is not life. Reality is, people's bodies are complex and their conditions, even though it may be one thing, may have multiple underlying causes. It's our job, as researches, to try and uncover that.
PT is not just about doing exercises. That is the misconception. We are also researchers, caretakers, housekeepers, drivers, artists, mechanics, organizers, and cheerleaders.
What you should be doing is embrace the fact that you can be an individual that could make a difference in another person's life. Wasn't that the purpose that you applied to begin with?
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Devils advocate moment: And yet the profession promotes procedures like dry needling. I don't know about the people reading this, but I have never seen anything that is remotely supportive of the practice in the literature, nor is there a sound scientific framework/theory that makes it plausibly evidence based. its almost like we want to be able to do what Chiros do. e.g. Manipulate, dry needling (we don't call it adjusting or acupuncture but isn't it really the same thing?)
The OP has a point but then again so does Chocolatetruffle and many other posters on this thread.
The OP has a point but then again so does Chocolatetruffle and many other posters on this thread.
These are good points, and I definitely recognize the individuality of the patient and how it can make it hard to find evidence for intervention. I applied to PT because I wanted to significantly help others to help themselves find physical autonomy. I believe PT's do this, but I also believe there is an immense amount of things going on in the profession that work against this goal. I believe that most PT's are unconcerned with governing and regulating their own profession to improve its legitimacy and expedite its progress (aside from personal experience, I think membership rates and funding in the APTA is indicative of this). In other words, I believe I could be a good PT as an individual, but I am not sure I be comfortable being a part of the profession. I have met some rock star PT's from the APTA, the JOSPT, and various universities whose views are more similar to my own and they are fighting hard to progress the profession. I tend to get along with them a lot more than other PT's I have talked to. But they are a small group and it seems daunting for me to try to enter the profession in such a minority.
I am not concerned with finding something 100% factual, but I am concerned with finding something that is either well-evidenced or, if not (maybe no one funds studies so there is no evidence for or against), something that is self-evident. I guess we all have different standards for evidence and effectiveness and PT just does not yet meet my standard given its cost (for the patient), its degree requirements and what it claims to do for a patient. (Just bolding this because after writing it I realize it is probably the best summary of my frustrations).
To speak to trushseeker's point, it does really bother me that the profession is trying to embrace things like dry-needling, and I think dry-needling is a good contemporary example of some of my frustrations with the profession. It also bugs me that certain passive modalities and obsolete interventions are on the NPTE.
Thanks everyone for helping me figure stuff out.
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you mentioned above that "most PTs are unconcerned with governing and regulating their own profession" I think that the word "most" is a stretch. Too many, yes, but most, I don't think so.
Do what you need to do.